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Medical Aesthetics
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Name
*
First
Last
Email
*
Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Birth Date
*
MM slash DD slash YYYY
General Information
Are you currently under the care of a physician?
*
Yes
No
If yes, what for?
Are you currently under the care of a dermatologist?
*
Yes
No
If yes, what for?
Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation?
*
Yes
No
Do you have any of the following medical conditions? (check all that apply)
Cancer
Herpes
HIV/AIDS
Seizure disorders
Thyroid imbalance
Diabetes
Arthritis
Keloid scarring
Hepatitis
Blood clotting abnormalities
High blood pressure
Frequent cold sores
Skin disease/lesions
Hormone imbalance
Any active infection
Do you have any other health problems or medical conditions? Please list
Have you every had an allergic reaction to any of the following? (check all that apply)
Food
Aspirin
Hydroquinone
Latex
Hydrocortisone
Lidocaine
Other
Medications
What oral/topical medications are you presently taking?
*
Birth control pills
Hormones
None
Other
Are you on any mood altering or anti-depressant medication?
*
Yes
No
Have you ever used Accutane?
*
Yes
No
If yes, when did you last use it?
What herbal supplements do you use regularly?
History
Have you ever had laser hair removal?
*
Yes
No
Have you had any recent tanning or sun exposure?
*
Yes
No
Do you form thick or raised scars from cuts or burns?
*
Yes
No
Do you have Hyperpigmentation (darkening of the skin), or Hypopigmentation (lightening of the skin or marks) after physical trauma?
*
Yes
No
If yes, please explain
Have you ever had local anesthesia with licodaine?
*
Yes
No
Which of the following best describes your skin type?
Always burn, never tan
Always burn, sometimes tan
Sometimes burn, always tan
Rarely burn, always tan
Brown, moderately pigmented skin
Heavily pigmented skin, very dark hair
Female Clients
Are you pregnant or trying to become pregnant?
Yes
No
Are you breastfeeding?
Yes
No
Are you using contraception?
Yes
No
Signature
Today's Date
*
DD slash MM slash YYYY
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